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Breadcrumb

  1. Home
  2. Lessons Learned

Lessons Learned

Contributing Factors

  • Human Error (52)
  • Situational Awareness (50)
  • Change in Procedures, Equipment, or Materials (35)
  • Design Flaw (32)
  • Training Issue (32)
  • Decision Making (21)
  • Equipment Failure (21)
  • Inadequate Inspection (21)
  • Lack of Protocol/SOP (16)
  • Inadequate Maintenance (14)
  • Incorrect Protocol/SOP (14)
  • Deficiency in Procedures (12)
  • Communication (11)
  • Failure to Follow Procedure (11)
  • Operation Induced Damage (11)
  • Inadequate System Monitoring/Oversight (10)
  • Flammable Mixture in Confined Area (9)
  • Individual Action (8)
  • Incomplete O&M procedures (7)
  • Material Incompatibility (6)
  • Improper Purging Procedure (5)
  • Abnormal Operations (4)
  • Fatigue (4)
  • Inadequate Management of Change (4)
  • Inadequate venting design (4)
  • Lack of Hydrogen Detection Equipment (4)
  • Improper Labeling (3)
  • Weather (3)
  • Accountability (2)
  • Lack of Component Listing (2)
  • Software Error (2)
  • Unknown (2)
  • Laboratory Clutter (1)
  • Management Planning Deficiency (1)
  • manufacturer not sure what led to the failure (1)

Damage and Injuries

  • Property Damage (114)
  • None (85)
  • Minor Injury (28)
  • Lost Time Injury (19)
  • Human Life (15)
  • Facility closed until repair completed (11)
  • Facility Closure (6)
  • Project Delay (2)
  • 000 bill from the fire department for their response (1)
  • Environmental (1)
  • Laboratory equipment damage (1)
  • Operations delayed until regulator replaced (1)
  • Plant shutdown for maintenance (1)
  • Property damage amounted to singeing of roof canopy and no more than $300 in total damage. (1)
  • Received a $10 (1)
  • Shutdown to Upgrade Equipment with Additional Monitoring (1)
  • Substantial damage to residential homes adjacent to the facility (1)

Equipment

  • Piping (39)
  • Valve (39)
  • Gas cylinder (21)
  • Measurement / Sensing Device (19)
  • Vessel (18)
  • Burst Disk (14)
  • Electrical Equipment (14)
  • Compressor (13)
  • Glassware (12)
  • Fueling Dispenser (11)
  • Batteries (10)
  • Gaseous Hydrogen Delivery Vehicle (10)
  • Flexible Tubing (8)
  • Glove Box/Fume Hood (8)
  • Fueling Hose (7)
  • Gasket (7)
  • Hydrogen tubes (7)
  • Venting System (7)
  • Exhaust Fan (6)
  • Flange (6)
  • Heat Exchanger (6)
  • Liquid Hydrogen Delivery Vehicle (6)
  • Process Vessels (6)
  • Vent line (6)
  • Crafts Tools (5)
  • emergency shut down procedures and disconnects (5)
  • Fire-Extinguishing Equipment (5)
  • Fuel Cell (5)
  • Fuel Cell Vehicle (5)
  • Pressure Transducer (5)
  • Bolts (4)
  • Furnace (4)
  • Electrical Safety Interlocks (3)
  • Main Generator Stator Cooling Water System (3)
  • Pump (3)
  • Reactor (3)
  • Vent piping and cap (3)
  • Water Electrolysis System (3)
  • Battery Storage Container (2)
  • Construction Tools (2)
  • Gas Chromatograph (2)
  • High-Pressure Reactor Cell (2)
  • IR spectrometer (2)
  • manual valve (2)
  • Microbiological Anaerobic Chamber (2)
  • Open Flame Burner (2)
  • Positive Pressure Fan (2)
  • quick disconnect fittings (2)
  • Vent Stack Cap (2)
  • Laboratory-scale oil bath (1)

Probable Cause

  • Equipment Failure (90)
  • Human Error (34)
  • Design Flaw (28)
  • Inadequate Maintenance (21)
  • Failure to Follow Standard Operating Procedures (20)
  • Incomplete Operating and Maintenance Procedures (13)
  • Deficiency in Procedures (12)
  • Abnormal Operations (10)
  • Inadequate Equipment (9)
  • Material Incompatibility (9)
  • Hazard Not Identified in Advance (8)
  • Inadequate Inspection (8)
  • Inadequate Venting Design (8)
  • Lack of Protocol/SOP (8)
  • Flammable Mixture in Confined Area (7)
  • Management Planning Deficiency (7)
  • Lack of Hydrogen Detection Equipment (6)
  • Improper/Inadequate Equipment Labeling (5)
  • Incorrect Standard Operating Procedure (5)
  • Inadequate Handling/Transporting/Storage Techniques (4)
  • Inadequate Management of Change (4)
  • Inadequate System Monitoring/Oversight (4)
  • Vehicle Collision (4)
  • Improper Purging Procedure (3)
  • Improper Relief Valve Set Point (3)
  • Incorrect Engineering Hazard Analysis Calculation (3)
  • Fault in original weld (2)
  • Improper Fire Fighting Technique (2)
  • Unknown (2)
  • Change in Procedures (1)
  • Equipment (1)
  • Laboratory Clutter (1)
  • Manufacturing defects (1)
  • Non-certified Electrical Wiring (1)
  • or Materials (1)
  • Poor housekeeping (1)
  • Training Issue (1)

Pagination

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What is H2 Lessons Learned?

Latest Reports

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Lessons Learned Corner

Corner Archives
Adequate Ventilation of Battery Charging Facilities
Learning from Burst Disk Failures
Hydrogen Compatibility of Materials
Management of Change
H2 Tools is intended for public use. It was built, and is maintained, by the Pacific Northwest National Laboratory with funding from the DOE Office of Energy Efficiency and Renewable Energy's Fuel Cell Technologies Office.

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